Robert M. Szabo
DEFINITION
Disorders of the distal radioulnar joint (DRUJ) are a significant source of wrist pain for patients.
The etiology of symptoms referable to this joint includes displaced fractures or malunions of the distal radius, which cause pain with forearm pronation–supination, and tears of the triangular fibrocartilage complex (TFC), which result in DRUJ instability, mechanical symptoms, and pain.
Both Madelung deformity23 and rheumatoid arthritis (RA) can display secondary incongruity of the DRUJ, causing pain and loss of forearm rotation. Radial head fracture treated by resection and subsequent shortening of the radius (EssexLopresti lesion) also can result in painful incongruity or instability of the DRUJ.
Management of DRUJ pain, incongruity, or instability alone is challenging, but the Sauvé-Kapandji procedure is one solution that treats all three disorders.11,20
ANATOMY
The DRUJ is a distal articulation in the biarticulate rotational arrangement of the forearm that allows one degree of motion: pronation and supination. The sigmoid notch of the radius is concave, with a 15-mm radius of curvature.
The ulnar head is semicylindrical, with a radius of curvature of 10 mm, and has an articulate convexity of 220 degrees. It is surrounded by the ulnolunate and ulnotriquetral ligaments, which originate from the palmar radioulnar ligament near the ulnar styloid.
The TFC is a fibrocartilaginous disc originating at the junction of the lunate fossa and the sigmoid notch inserting at the base of the ulnar styloid. Its central portion is cartilaginous and avascular and is designed for weight bearing.
The peripheral margins, the dorsal and palmar radioulnar ligaments, are thick lamellar cartilage designed for tensile loading. They are well vascularized from the palmar and dorsal branches of the anterior interosseous artery and from the ulnar artery.
The ulnar styloid acts as a strut on the end of the ulna to stabilize the ulnar soft tissues of the wrist. The sheath of the extensor carpi ulnaris (ECU), the ulnocarpal ligaments, and the TFC attach at the base of the ulnar styloid and together are known as the TFCS.
The radius of curvature of the head of the ulna does not equal that of the sigmoid notch. In the extremes of pronation–supination, less than 10% of the ulnar head may be in contact with the notch. In pronation, the ulnar head translates 2.8 mm dorsally from a neutral position and in supination the ulnar head translates 5.4 mm volarly from a neutral position.
The stability of the DRUJ comes from the joint surface morphology, the joint capsule, the dorsal and palmar radioulnar ligaments, the interosseous membrane, and the musculotendinous units that cross the joint, primarily the ECU and pronator quadratus (PQ). The PQ actively stabilizes the joint by coapting the ulnar head in the sigmoid notch in pronation and passively by viscoelastic forces in supination. The ECU is retained over the dorsal distal ulna by a separate fibro-osseous tunnel deep to and separate from the extensor retinaculum, allowing unrestricted rotation of the radius and ulna.18
PATHOGENESIS
Traumatic injury to the wrist can lead to derangement of the DRUJ, which can result in instability and eventually painful degenerative changes.
Distal radial malunions with dorsal or volar subluxations or dislocations of the DRUJ produce secondary rupture, elongation, or functional shortening of the distal radioulnar ligaments.
Arthritis of the DRUJ is a common complication of Colles fractures, particularly when fractures involve the sigmoid notch.
Congenital disorders such as Madelung disease as well as traumatic epiphyseal closures of the distal radius can produce marked positive ulnar variance with dorsal dislocation of the DRUJ.
In the rheumatoid wrist, progression of distal radioulnar synovitis typically results in the “caput ulnae syndrome” as described by Backdahl, which consists of the following:
Wrist weakness with pain on pronation and supination
Dorsal prominence of the ulnar head
Limitation of pronation and supination
Swelling of the distal radioulnar area
Secondary tendon changes with possible extensor tendon rupture and ECU subluxation1
If allowed to progress without intervention, the carpus will eventually fall in a more ulnarward and palmarward direction, with strength, mobility, and function all suffering.21
A chronically unstable DRUJ without degenerative changes can be treated with various soft tissue reconstructions, depending on the abnormalities and underlying pathology.
As a group, many of these reconstructions fail to restore stability; even if stability is restored, limitation of forearm motion persists.
NATURAL HISTORY
The natural history of DRUJ derangement is painful limitation of forearm rotation, often with additional functional deficits.
When positive ulnar variance exceeds a few millimeters, additional limitations of wrist flexion–extension as well as radial–ulnar deviation movements can occur.
PATIENT HISTORY AND PHYSICAL FINDINGS
Clinical evaluation begins with a detailed and accurate history.
A history of fracture involving the forearm or wrist is clearly important. Patients may recall a specific injury involving damaging forces of torque with axial load applied to the involved wrist and forearm.
The patient's occupation or hobbies may give insight into the mechanism of injury as well as the most important functional deficits currently experienced by the patient.
A complete medical history is important, including questions about inflammatory arthritis or osteoarthritis.
DRUJ pathology most often causes ulnar-sided wrist pain, diminished grip strength, limited forearm pronation and supination, and limited wrist ulnar deviation.
Pain is exacerbated with activity and increases with resisted rotation of the forearm.
With large ulnar length discrepancy (positive ulnar variance), limited flexion–extension also can be seen.
During the physical examination, the clinician should determine whether loss of forearm rotation is solely due to DRUJ pathology or if there is a concurrent problem at the proximal radioulnar joint or interosseous membrane. Other sources of wrist pain and dysfunction must be ruled out.
The clinician should check for instability or chronic dislocation of the joint, comparing the injured with the uninjured wrist.
The patient's normal and affected wrist and forearm ranges of motion, both active and passive, should be measured. A rigid endpoint with loss of motion suggests bony pathology such as fracture malunion, whereas a soft endpoint with limited motion suggests soft tissue contractures.
The clinician should carefully palpate, ballote, and compress around the DRUJ and compare the findings to the opposite side. Grip strength measurements should be checked bilaterally.
When evaluating patients with RA, the clinician should try to distinguish the pain and instability of the DRUJ from radiocarpal and midcarpal joint symptoms by careful palpation, ballottement, and compression of areas around the DRUJ, comparing the degree of symptoms elicited by forearm rotation versus wrist flexion–extension.
Examinations to perform include:
Piano key test. The test, which isolates DRUJ disorders, is positive if it causes pain and/or crepitus.
Selective anesthetic injections. The test is positive when precise, selective injection of anesthetic into the area eliminates pain and improves function. Injections help to confirm pathologic changes and can be used to distinguish intraarticular from extra-articular lesions.
Ulnocarpal compression test. A positive test reproduces the ulnar-sided wrist pain and grinding by translating force across the TFC. It also isolates pathologic changes in the TFC.
Lunotriquetral (Regan) shuck test. Pain, sometimes with increased joint mobility and grinding, represents a positive test. This test detects and assesses abnormalities or pathologic conditions associated with the lunotriquetral joint.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Standard neutral rotation posteroanterior (PA), lateral, and ulnar variance radiographs of the wrist should be obtained and compared with the normal side. The clinician should look for evidence of fractures, arthritic changes, bone lesions, and distal ulna position relative to the radius.
Forearm and elbow radiographs are obtained if there is a history of an elbow injury (especially a radial head fracture) or forearm injury.
If ulnocarpal abutment is suspected, a PA radiograph is obtained with the forearm in pronation and the fist clenched. This will increase ulnar variance and potentially reveal ulna impaction.
CT is best to evaluate subluxation and articular congruity of the distal radioulnar joint.4,18 To assess the distal radioulnar articular surfaces, simultaneous views are obtained of both extremities with the forearms in neutral rotation, full supination, and full pronation.
MRI with single-injection gadolinium arthrography (MRA) is a good way to evaluate TFC lesions as well as the integrity of the scapholunate and lunotriquetral interosseous ligaments.
DIFFERENTIAL DIAGNOSIS
Extensor carpi ulnaris tendinitis or subluxation
Flexor carpi ulnaris tendinitis
Pisotriquetral arthritis
Lunotriquetral ligament tear
TFC tear
Acute DRUJ dislocation
NONOPERATIVE MANAGEMENT
A trial of nonoperative management is helpful for some patients with DRUJ disorders.
Minor strains of the DRUJ capsule or sprains of other ulnarsided wrist ligaments may respond to rest, ice after activity, wrist splints, and oral anti-inflammatory medications.
Easily reducible dislocations of the DRUJ can be treated by immobilization in a rigid splint or cast for 6 weeks.
Inflammation of the ulnar-sided wrist tendons often accompanies DRUJ problems.
Tendinitis should be treated first with stretching exercises, other physical therapy modalities, and sometimes a steroid injection before addressing the DRUJ surgically.
SURGICAL MANAGEMENT
The Sauvé-Kapandji procedure is especially useful for patients with RA. Despite advanced radiographic findings of radiocarpal or midcarpal arthritis, complaints of wrist pain can be relieved in many RA patients by addressing the DRUJ pathology with a Sauvé-Kapandji procedure.
Commonly, resection of the distal end of the ulna, the Darrach procedure, is recommended for patients with RA and ulnar-sided wrist pain. However, the inflammatory changes and deforming forces acting on the hand and wrist in RA tend to cause palmar and ulnar translocation of the wrist, resulting in decreased mobility, strength, and function. Removal of the distal ulna exacerbates and accelerates the problem.
FIG 1 • Radiographs from a patient with rheumatoid arthritis before (A) and after (B,C) a Sauvé-Kapandji procedure.
With the Sauvé-Kapandji procedure, the retained distal ulna provides bony support for the ulnar corner of the wrist to help stabilize against the palmar–ulnar slide of the carpus (FIG 1). In addition, the important attachments of the ulnocarpal complex are preserved.21
The Sauvé-Kapandji procedure is also beneficial in the treatment of DRUJ disorders resulting from trauma.
In cases of wrist trauma with ulnar-sided ligamentous injury and incompetence, retaining the ulnar head, as is performed with a Sauvé-Kapandji reconstruction, maintains the ulnocarpal buttress and the TFC to allow a more physiologic transmission of load from the hand to the forearm.
The osteotomy made in the ulna in the Sauvé-Kapandji procedure allows as much shortening as is needed to match the level of the radius while retaining supination and pronation.
Other surgical options include hemiresection and interposition arthroplasty, matched resection of the distal part of the ulna, Darrach resection, and more recently prosthetic replacement.2
Preoperative Planning
The clinician should review preoperative radiographs and carefully assess whether fixation of the ulna head can be performed before any osteotomy or if an osteotomy and excision of the ulna segment needs to be done first to restore proper length and head position into the sigmoid fossa.
Positioning
The patient is positioned supine with the upper extremity on a hand table.
A pneumatic tourniquet is placed on the arm.
An intraoperative fluoroscope is draped sterile and made available throughout the procedure.
TECHNIQUES
AUTHOR'S PREFERRED TECHNIQUE FOR THE SAUVÉ-KAPANDJI PROCEDURE
Incision and Dissection
Make a straight longitudinal incision, 6 to 8 cm long, along the ulnar border of the distal forearm.
An alternative incision may be used if additional procedures are planned at the same sitting. For example, in patients with RA, often the Sauvé-Kapandji procedure needs to be combined with another soft tissue procedure such as a dorsal wrist synovectomy, tenosynovectomy, or tendon transfer to treat extensor tendon ruptures that result from the caput ulnae syndrome. If that is the case, start the incision more dorsally to facilitate exposure for the additional procedure, and then extend it proximally and obliquely to expose the distal ulna.
Identify the dorsal cutaneous branch of the ulnar nerve and protect it throughout the case (TECH FIG 1).
Expose the distal 4 to 6 cm of the ulna extraperiosteally through the interval between the ECU and flexor carpi ulnaris (FCU).
TECH FIG 1 • Identification and mobilization of the dorsal sensory ulnar nerve, which is tagged with a rubber dam. Notice a dorsal branch under the probe.
Osteotomy of the Ulnar Diaphysis
Select the appropriate level for an osteotomy of the ulnar diaphysis (TECH FIG 2A).
Cut the bone just proximal to the flare of the ulnar head; this will leave enough of the distal ulna to accommodate two fixation screws.
Confirm with fluoroscopy that the proposed osteotomy site is appropriate.
Make a second cut proximal and parallel to the first (TECH FIG 2B), and remove a 10to 14-mm segment of ulna (TECH FIG 2C). Resect the periosteum in the region of the gap and irrigate thoroughly to remove bone debris.
If there is a positive ulnar variance, remove a correspondingly longer segment of the ulna so that when the ulnar head is recessed to neutral ulnar variance, the resulting gap will be adequate.
Save the removed bone for subsequent grafting into the DRUJ arthrodesis site (TECH FIG 2D).
TECH FIG 2 • A. Measure the osteotomy resection. As shown here, take into consideration the amount of shortening needed to obtain neutral ulna variance. B. Make the proximal and distal osteotomies using a microsaw. C.Removal of the resected ulna. Preserve the pronator quadratus, which is left behind for later use. D. Harvest the cancellous bone from the resected ulna.
Distal Radioulnar Joint Exposure and Preparation
Expose the DRUJ with a dorsoulnar capsulotomy just radial to the ECU tendon.
Denude both the ulnar head and sigmoid fossa of the radius of all remaining cartilage to create flush surfaces of cancellous bone on each side of the arthrodesis site, and pack the harvested cancellous bone from the removed ulna segment (TECH FIG 3).
In patients with severe bone loss, after decortication of the corresponding articular surfaces of the DRUJ, sculpt the resected segment of the ulna to fit into the space between the ulnar head and sigmoid notch as a corticocancellous bone graft.
TECH FIG 3 • Curette the sigmoid notch of any remaining cartilage and then pack in the bone graft from the resected ulna.
Fixation
Cannulated self-tapping screws are preferable to K-wires for fixation of the arthrodesis site.
K-wires can irritate cutaneous nerves when buried or can cause wound problems when placed percutaneously.
There is usually no need to remove hardware when screws are used, and rehabilitation can begin sooner because of secure fixation.
Cannulated screws over guidewires allow accurate screw placement and facilitate the alignment of the cortices of the distal ulna and radius.
Establish ulnar neutral variance by moving the ulnar head proximally or distally to bring its distal surface parallel with the distal radius surface; confirm correct placement fluoroscopically.
Do this while holding the forearm in neutral rotation with the patient's elbow resting on the operating table while supporting the forearm perpendicular to the table in neutral rotation.
Temporarily fix the ulnar head to the sigmoid notch of the distal part of the radius with a single K-wire, and ensure proper position with fluoroscopy.
While maintaining neutral forearm rotation, drill two guidewires across the DRUJ to stabilize the ulnar head in proper position.
Place one wire a few millimeters proximal to the subchondral bone of the distal ulna, and position the second wire proximal enough to allow for seating of both screw heads without impingement (TECH FIG 4A).
TECH FIG 4 • A. Placement of the two K-wires to stabilize the ulna head. B. Drill over the K-wires, measure, and put in the screws.
Confirm correct placement of the guidewires with fluoroscopy.
Advance the distal wire into the far (radial) cortex of the radius and measure for screw length.
The proximal screw provides rotational control and needs only tricortical fixation. It can be 5 mm shorter than the distal screw.
After the screw lengths are measured, advance the wires through the skin to the radial side of the forearm with a mallet and grasp them with a clamp to avoid having the wire come out during drilling and screw placement.
With a mallet, the chances of injuring a branch of the radial sensory nerve branch are less than those with a power driver.
Drill over the guidewires with a cannulated drill bit (TECH FIG 4B).
Pack additional cancellous bone harvested from the excised ulnar segment into the DRUJ space.
Insert the selected screws over the guidewires while manually compressing the ulnar head against the radius.
Tighten the distal screw first to avoid compressing the radial and ulnar shafts together and levering the ulnar head out of position.
Do not use lag-screw technique on the proximal screw, and avoid tilting the head of the ulna; it must remain parallel to the long axis of the ulnar shaft.
Extensor Carpi Ulnaris Stabilization of the Proximal Ulna Stump14,15
After fixation of the DRUJ, drill a 3.5-mm hole from the dorsoulnar aspect of the ulnar shaft proximal stump into its intramedullary cavity.
TECH FIG 5 • Modification of the Sauvé-Kapandji procedure with ECU tenodesis as described by Minami et al.14 After the Sauvé-Kapandji procedure, a 3.5-mm hole was drilled from the dorsoulnar aspect of the ulnar shaft into the intramedullary cavity. The ECU tendon was then split in the central sulcus and the radial half released at the ulnocarpal level. It was then reflected proximally, leaving it attached at the musculotendinous junction. This proximally based strip was then passed into the medullary canal through the drill hole, retrieved at the distal stump of the ulna, and then sutured back on itself in an interlacing fashion.
Split the ECU tendon in the central sulcus and release the radial half at the ulnocarpal level.
Reflect this half of the ECU proximally, leaving it attached at the musculotendinous junction.
Pass this proximally based strip, approximately 6 to 8 cm long, into the medullary canal through the drill hole, and retrieve it at the distal stump of the ulna, pulling it distally under moderate tension, and then suture it back onto itself in an interlacing fashion (TECH FIG 5).
Flexor Carpi Ulnaris Stabilization of the Proximal Ulna Stump 12
Over a distance of 8 to 10 cm through the volar aspect of the incision, isolate a distally based slip of FCU tendon (measuring about half the width of the tendon) attached to the pisiform.
Drill a 4to 4.5-mm hole on the volar cortex, 1 cm proximal to the end of the osteotomized surface of the proximal ulnar segment.
This is facilitated by inserting the drill bit obliquely through the medullary cavity in a dorsal to volar direction.
Pass the slip of FCU tendon deep to the FCU muscle through the distal end of the ulnar stump, and loop it back on itself, securing it with nonabsorbable suture (TECH FIG 6).
Suture the tendon under moderate tension, keeping the forearm in neutral rotation and the wrist in neutral flexion–extension and neutral radioulnar deviation.
Pull the pronator quadratus muscle into the gap in the ulna and suture it to the volar aspect of the tendon sheath of the ECU.
Reattach the sixth dorsal compartment within the groove on the ulnar head and close the wound.
TECH FIG 6 • Modification of the Sauvé-Kapandji procedure with FCU tenodesis as described by Lamey and Fernandez.12
Lateral aspect of the wrist, showing stabilization of the proximal ulnar segment with use of a distally based slip of the FCU tendon.
Wound Closure
Make sure that there is a gap of 10 to 12 mm between the proximal and distal ulnar segments.
Suture the fascia of the underlying pronator quadratus into the gap to prevent reossification across the pseudarthrosis site and stabilize the stump of the ulnar shaft (TECH FIG 7A).
Repair the retinacular compartments (TECH FIG 7B) and close the skin in routine fashion.
TECH FIG 7 • A. Suturing the pronator quadratus into the gap. B. Closure of the retinaculum.
TECHNIQUE FOR CASES CHARACTERIZED BY POOR BONE QUALITY (FUJITA TECHNIQUE 8,9 )
Make a 7-cm longitudinal skin incision on the dorsal aspect of the wrist centered on the ulna head (TECH FIG 8A).
Open the fourth dorsal compartment. Divide the septum between the fourth and fifth compartments and reflect the retinaculum ulnarly to preserve a single common retinacular flap.
Retract the extensor digitorum communis and extensor digiti minimi tendons radially and perform a neurectomy of the terminal branch of the posterior interosseous nerve.
Incise the capsule of the DRUJ and dissect the distal part of the ulna subperiosteally.
Perform an oblique osteotomy with an oscillating saw 30 mm proximal to the distal end of the ulna and excise the ulna head (TECH FIG 8B).
Perform a synovectomy of the DRUJ and remove the periosteum of the resected portion of the ulna.
Interpose the pronator quadratus muscle at the osteotomy site.
Drill a hole 10 mm in diameter at the sigmoid notch of the radius while viewing the distal articular surface of the radius through the TFC, which is usually ruptured. Do not penetrate the subchondral bone (TECH FIG 8C).
Remove all soft tissue from the resected portion of the ulna and then rotate it 90 degrees and insert the cut end of the ulnar graft into the hole in the radius, creating a shelf 12 to 15 mm long.
Impact the ulnar graft into the subchondral and cancellous bone of the distal part of the radius without penetrating the radial cortex, and fix it in the drill hole with a cancellous bone screw (TECH FIG 8D). Do not overtighten the screw.
Cover the graft with the joint capsule contiguous with a periosteal flap.
Mobilize and relocate the ECU tendon by dissecting the septum between the fifth and sixth compartments.
If subluxation of the ECU tendon is evident during rotation of the forearm, reflect the distal portion of the periosteal flap ulnarly beneath the ECU tendon to act as a sling, and suture it to the adjacent soft tissue to restrain the ECU in a dorsal and radial position over the graft.
Close in the fashion previously outlined.
TECH FIG 8 • Modification of the Sauvé-Kapandji procedure with the distal ulna used as a bone peg as described by Fujita et al.9 A. Make a 7-cm longitudinal skin incision on the dorsal aspect of the wrist centered on the ulna head. B. Perform an oblique osteotomy with an oscillating saw 30 mm proximal to the distal end of the ulna and excise the ulna head. C. Drill a hole 10 mm in diameter at the sigmoid notch of the radius while viewing the distal articular surface of the radius through the TFC, which is usually ruptured. Do not penetrate the subchondral bone. D. Remove all soft tissue from the resected portion of the ulna and then rotate it 90 degrees and insert the cut end of the ulnar graft into the hole in the radius, creating a shelf 12 to 15 mm long. Impact the ulnar graft into the subchondral and cancellous bone of the distal part of the radius without penetrating the radial cortex, and fix it in the drill hole with a cancellous bone screw.
POSTOPERATIVE CARE
Rehabilitation after the Sauvé-Kapandji procedure follows guidelines published by Skirven.16
Postoperatively, a bulky dressing with plaster splints extending above the elbow, maintaining the forearm in neutral position, is applied for 7 to 10 days.
Sutures are then removed and the patient is given a removable, lightweight splint to support the wrist.
Hand therapy is initiated with an emphasis on gentle active wrist, digit, and forearm rotation exercises.
Except for exercise sessions and bathing, the splint is worn at all times.
In the postoperative period, the goal is to allow adequate healing by supporting and protecting the arthrodesis site from stress, followed by gradual restoration of functional mobility without sacrificing the stability of the ulnar shaft or the arthrodesis.
The arthrodesis is protected from loading forces for 4 to 6 weeks.
When the arthrodesis appears healed radiographically, usually 8 weeks postoperatively, light strengthening exercises are initiated. Heavy lifting and forearm torque are avoided until 3 months postoperatively.
For conservative management of postoperative instability of the ulnar shaft, Skirven has recommended a small, cuff-style splint to support the pseudarthrosis site and help stabilize the ulnar shaft.16
The splint, which is made of thermoplastic material, extends from the distal radius ulnarly to a few centimeters proximal to the pseudarthrosis site.
An adjustable strap allows the patient to set the tension on the splint to provide comfort and the level of stability required for specific activities.
OUTCOMES
There is a broad international experience with this operation on many patients.
Zimmermann in Austria retrospectively reported on 43 patients' clinical results and DASH questionnaires 8 years (range 5 to 12 years) after a Sauvé-Kapandji operation.24 Forearm rotation improved in all patients. Ulnar wrist pain was diminished in 97% of the patients, and 9% had mild pain at the proximal ulnar stump. Grip strength compared to the contralateral side improved from a preoperative mean of 38% to a postoperative mean of 55%. The mean DASH score was 28 points (range 0 to 53 points). In all cases the arthrodesis fused within 8 weeks.
In Australia, Millroy reported on 81 procedures in 71 patients and found that “almost all patients were pain free during normal activity, although 7 experienced discomfort with overuse.”13
In Belgium, De Smet conducted a prospective survey on 84 patients treated for posttraumatic arthritis of the DRUJ with the procedure.7 According to the Mayo wrist score, there were 20 excellent, 34 good, 18 fair, and 12 poor results, with an overall satisfaction rate of 74%.
In Denmark, Jacobsen found that 15 of 17 employed patients returned to work.10
In England, Carter found that 86% of his patients would have the operation again.3
In Germany, Daecke looked at the functional outcomes of 56 patients with the DASH and Mayo wrist scores as well as clinical results.5 Although only 50% of patients were free of symptoms during heavy labor, 95% had excellent results. The postoperative DASH score was 24.2 ± 22.5 and the Mayo wrist score was 76.1 ± 17.6.
In Switzerland, Lamey reported on 18 patients who underwent the Sauvé-Kapandji procedure with the FCU tenodesis of the ulna stump.12 There were 6 excellent, 7 good, 4 fair, and 1 poor Mayo wrist scores. Eight of the patients who had performed heavy manual labor before the injury were able to return to work full-time without restrictions.
Many other studies report similar outcomes, confirming the utility and broad appeal of this operation.
COMPLICATIONS
The main source of complications from the Sauvé-Kapandji procedure is the distal stump of the ulna.
Pain, ulnar impingement syndrome, and a feeling of instability of the ulnar shaft have been reported, but these symptoms are usually transient and resolve by 3 months postoperatively.
Significant instability of the ulnar shaft is more commonly reported after the Darrach procedure, but it can also occur if too much bone is resected during the described procedure.6
To prevent instability, the surgeon should carefully stabilize the ulnar stump with pronator quadratus fascia advancement, should place the osteotomies as far distally as possible, and should not resect too much bone.
The surgeon should also avoid excessive stripping of the interosseous membrane. A soft tissue tube should surround the pseudarthrosis site to connect and stabilize the proximal and distal ulnar segments.
Despite these precautions, painful instability of the distal ulnar stump can occur. In this scenario, the stump can be stabilized by using a strip of the ECU or FCU tendon based on its distal attachment.
Another complication from the Sauvé-Kapandji procedure is ossification of the pseudarthrosis site.6
The pronator quadratus should be interposed in the ulnar gap after the osteotomy is complete and the ulnar segment should be removed extraperiosteally to minimize the occurrence of this complication.
If ossification does occur, the bone may be resected when mature. The patient should then immediately begin forearm rotation exercises.
Injury of the dorsal cutaneous branch of the ulnar nerve is a potential problem and can be avoided with careful dissection.
Wada and Ishii reported closed rupture of a finger extensor tendon after the Sauvé-Kapandji procedure. They postulated that this was due to the ulnar shaft stump's being left distal to the edge of the extensor retinaculum, causing attritional rupture of the tendon trapped between the bone edge and the retinaculum.22
This could be avoided by contouring the ulnar shaft edge to a smooth edge and covering the stump with the interposed pronator quadratus.
Painful neuromas of the dorsal sensory branch of the ulna nerve have also been reported.
Lamey and Fernandez noted that this may be more common when harvesting a distally based slip of the FCU from one incision. They recommend this be done from a second incision.12
Some patients develop hardware pain from palpable screw heads. These screws can be removed.
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